Wednesday, November 4, 2015

Closing General Session: ‘Stop asking for a seat at the table…we belong at the head of the table’

In April in Baltimore, after the civil unrest that followed the death of Freddie Gray while in police custody, city Health Commissioner Leana Wen wasn’t entirely sure what the role of the health department should be in helping the city recover.

But she and her colleagues quickly realized that 13 of the city’s pharmacies had burned down, leaving some of Baltimore’s most vulnerable residents without access to life-saving medications. In response, the public health department organized to bring medicine, food and basic supplies to those in need. The agency launched a 24-hour hotline and began going door to door to offer their help. The story is emblematic of public health — we respond when people are in need. But what’s even more telling about this story is how the people on the other side of all those doors reacted, Wen said.

People automatically assumed that the offer of help was linked to a political campaign for a particular candidate or that they were being asked to fill out another survey. It was a difficult reminder that even though public health workers have the best of intentions, histories of inequity and disenfranchisement continue to frame the context in which public health is practiced. And without acknowledging those histories and allowing them to inform public health interventions, sustainable health improvements may remain out of reach.

“Sometimes the problem that we see can seem so big, it’s almost like you can’t start anywhere,” Wen said to a packed Closing General Session audience on Wednesday afternoon in Chicago, where more than 13,000 public health practitioners had attended the APHA Annual Meeting. “But each of us can play a role. …We would never wait if it was a sick patient. This is a sick system, so let’s do something today.”

Digging deep into the underlying social determinants of health was a common call to action among the session’s speakers, especially as public health moves into a post-Affordable Care Act era and can slowly, though not entirely, begin to shift its collective attention away from access to care issues. Among those underlying determinants is racism.

New APHA President Camara Jones announced at the session that she intends to take APHA and its partners on a national campaign against racism, which she defined as a systemic and institutional issue, not an individual characteristic or personal moral failing. As we move forward on this journey to achieve health equity, Jones called on the audience to keep three principles in mind: valuing all individuals and populations equally; recognizing and rectifying historical injustices; and providing resources according to need.

Public health, Jones said, is built on a commitment to achieving social justice.

“If we concentrate more attention to how racism is sapping the strength of whole societies…we will have more of us intent on dismantling the system,” Jones said.

Those social determinants of health are the new frontier of public health, said session keynote speaker Karen DeSalvo, acting assistant secretary for health at the U.S. Department of Health and Human Services. Even though the U.S. spends the most on health care, we don’t have the best health outcomes — in fact, far from it compared to the enormous amounts we’re spending. And perhaps the reason for that, DeSalvo postured, is that we’re focusing too much on genetic codes, rather than ZIP codes. Indeed, even if we get to a place of “perfect” health care for everyone, it will only improve people’s health by 15 to 20 percent, she said. But what about the other 80 percent? That’s where public health comes in.

This new frontier of health, DeSalvo said, is a place where public health practitioners don’t just run health departments; they’re the chief health strategists for entire communities.

“We want to ensure the conditions in which people can be healthy,” she told attendees.

DeSalvo talked about her hometown of New Orleans, which used to be home to some of the worst health outcomes in the world. But after the devastation of Hurricane Katrina, residents and city officials made a choice: they wouldn’t return to a place of health inequities and poor health outcomes. In her role as New Orleans health commissioner, which she stepped into in 2010, DeSalvo said it was an opportunity to build a new kind of public health — one more nimble, flexible and able to meet the community where it lived, worked and played. Fortunately, DeSalvo, her colleagues and community partners achieved great success. A recent example: In one decade, New Orleans went from one of the least healthy cities to one that chose to go smoke free.

In this new frontier of public health, DeSalvo called on session attendees to work across sectors and support a health-in-all-policies approach.

“Stop asking for a seat at the table,” she said of public health. “We need to show that we belong at the head of the table.”

Indeed, focusing on the social determinants of health gives us an opportunity to engage with other agencies that haven’t traditionally worked with public health, said Julie Morita, commissioner of the Chicago Department of Public Health, during a panel that included Wen as well as Faisal Khan, director of the St. Louis County Department of Public Health. Morita told session attendees that in developing a new health plan for Chicago, one particular social determinant rose to the top: violence.

Violence, Morita said, is an attack on the health of our community. In response, Chicago health workers are engaging in a number of activities to prevent violence, including an effort to prevent retaliatory violence. As part of that effort, health workers reach out to the families of homicide victims within 24 hours of a homicide to offer psychological first aid and other services in an attempt to break the cycle of violence.

Wen, of Baltimore, noted that public health practitioners can use social justice-informed tools to get at underlying contributors to violence. For example, she asked session attendees, what if instead of seeing someone as simply a perpetrator of violence, we saw them as a victim of trauma? To that end, Wen said Baltimore is working to become a trauma-informed city in which city workers will be trained in knowing how to identify trauma and how to respond.

However, public health must also speak up about its accomplishments, Wen noted. For example, in Baltimore, which used to have one of the worst infant mortality rates in the country, the health department convened more than 100 community partners to tackle the preventable problem. The outcome: B’More for Healthy Babies. Today, the city is celebrating the lowest infant mortality rate in its history, a 50 percent decrease in sleep-related infant deaths and an 86 percent reduction in the number of children suffering from lead poisoning.

“We have to marry our statistics with our stories,” Wen said.

In St. Louis County, the civil unrest and protests that followed the killing of Michael Brown was a symptom of already existing conditions, such as racial segregation, concentrations of generational poverty, disenfranchisement, lack of access to care, and a complete disconnect from all the resources that enable people to make healthy choices, Khan told the audience.

“Ferguson was a classic example of a community under a toxic amount of stress,” he said.

Khan said that until late 2014, his agency was your typical health department, focusing on clinical services, with no earnest focus on digging deeper into underlying social issues. However, when Khan took on the role of director about 10 months ago, his first action was changing the agency’s official name from the department of health to the department of public health. It wasn’t just semantics, he said, it was meant to send a clear signal to everyone in the community as well as staff that the agency’s mission was now fundamentally different.

If we’re going to make real change, Khan told the audience, we have get out into the community and have uncomfortable conversations about inequality and racism. He then asked the hundreds of people in the room to stand up and repeat after him.

“I am a professional public health troublemaker,” Khan boomed. “And I am proud of it!”

See everyone next year in Denver for APHA’s 144th Annual Meeting and Exposition, which will have a theme of “Building the Healthiest Nation, Ensuring the Right to Health.” And don’t forget to sign our Generation Public Health pledge and join the movement to create the healthiest nation in one generation.

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